Avera Health's billing services officer details the system's pain points and what's ahead for 2023.
Economic hardships have been increasing each year for hospitals. Even worse, 2022 was the worst year financially for hospitals and health systems since the COVID-19 pandemic began, and revenue cycle leaders are not off the hook.
Declining operating revenue for health systems, payers squeezing even harder on denials, and a fundamental shift in the workforce have been creating trying times for our revenue cycle leaders.
These hardships are pushing leaders to consider changes in 2023 and as Amanda Schutz, billing services officer at Avera Health says, remedying staffing challenges and implementing automation will be a priority for the health system this year.
Staffing has been a primary challenge for Avera Health’s revenue cycle in the last few years, Schutz says. To stay competitive, Avera has had to allow for more flexibility during working hours and grant staff the ability to work from home.
To remedy further staffing challenges, Schutz plans to advocate for the revenue cycle to make greater financial investments in automation for 2023. “That could be through AI, bot technology, or any technology that allows us to be more efficient in our day-to-day work,” she says. “With the cost of staff, we have to get more creative when it comes to automation.”
Pictured: Amanda Schutz. Photo courtesy of LinkedIn.
“I’m excited to be part of our automation/technology discussion and decisions at Avera. This is an area that we need to continue to dig into and decide what technology will allow our revenue cycle to run more efficiently,” Schutz says.
Schutz will be joining us at this month’s Revenue Cycle Exchange to talk through these pain points and more.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
Prior authorizations and price transparency will be a main focus of advocacy for 2023.
Each year the American Hospital Association (AHA) releases an advocacy agenda focusing on key areas in need of “critical support” for hospitals and health systems, and this year, quite a few key areas will be focused on your revenue cycle.
“Hospitals and health systems are dealing with unprecedented challenges as they manage the aftershocks and aftermath of COVID-19. These include historic workforce shortages, soaring costs of providing care, broken supply chains, severe underpayment by Medicare and Medicaid, and an overwhelming regulatory burden, just to name a few,” the AHA said.
To address these challenges, this year’s agenda is broken down into four main areas of action:
Ensuring access to care and providing financial relief
Strengthening the healthcare workforce
Advancing quality, equity, and transformation
Enacting regulatory and administrative relief
Most of these key areas include specific agendas related to the revenue cycle.
The group says it wants to enact technological, legislative, and regulatory solutions to reduce administrative waste by streamlining prior authorization requirements and processes for hospitals so that clinicians can spend more time on patients rather than paperwork.
It also plans to support price transparency efforts by ensuring patients have access to the information they seek when preparing for care, including cost estimates when appropriate, and creating alignment of federal price transparency requirements to avoid patient confusion and overly burdensome duplication of efforts.
When it comes to surprise billing, the AHA says it plans to ensure that regulations to implement surprise medical billing protections for patients do not inadvertently restrict patient access to care.
Social determinates of health capture also made the agenda. The AHA says it will promote approaches to account for social risk factors in quality measurement programs where appropriate to ensure equitable performance comparisons and payment adjustments, and promote alignment and standardization of approaches to collecting, analyzing, and exchanging demographic and health-related social need data across federal agencies.
The AHA says it will work with Congress, the administration, regulatory agencies, courts, and others to positively influence the public policy environment for patients, communities, and the healthcare field.
There is much more than just revenue cycle-related challenges being addressed. The hospital association is also placing a focus on workplace violence, Medicare residency slots, the nursing shortage, and workforce diversity. Read more about those initatives here.
A new survey highlights the importance of digital options in improving the patient experience.
Does your revenue cycle have poor digital engagement options? Well, it might be costing you patients, a new survey shows.
At a time when a positive patient experience is playing a heavy role in overall reimbursement, a new report from Accenture says patients are becoming more comfortable switching providers when their current one isn’t meeting their needs.
According to the report, many patients are finding it difficult to navigate their care journey.
78% of patients that switched health systems cite ease of navigation factors as the reason for leaving. These factors include difficulties in doing business, bad experiences with front-end staff, and inadequate digital solutions, the report says.
The report, which surveyed 10,000 US consumers between October and November 2021, also highlighted the need for technology in the revenue cycle as digital engagement played a large role in provider loyalty.
According to the report, nearly 80% of “highly digital” patients are likely to stay with their providers. This is more than 20% greater than all other digital engagement categories, the report says.
Although the report doesn’t cite specific digital engagement options, digital front doors, streamlined patient portals, and digital billing options have all been linked to a more positive patient experience within the revenue cycle.
Now, The American College of Emergency Physicians, American College of Radiology, and American Society of Anesthesiologists are showing support to the TMA as the groups filed a joint amicus brief with the court.
The groups say the issues outlined in the TMA’s suit hinders physicians and facilities from engaging in fair contracting negotiations with insurers, which could threaten their ability to operate and may result in patients losing access to in-network care.
The initial administrative fee for the IDR process was set at $50 and it was announced in October 2022 it would remain at $50 for 2023, but in January, the agencies revealed a 600% hike in the fee due to increasing expenditures in the IDR process, among other reasons.
"The steep jump in fees will dramatically curtail many physicians’ ability to seek arbitration when a health plan offers insufficient payment for care," the TMA said.
The amicus brief also outlined the flawed qualifying payment amount (QPA) process.
The medical societies say the methodology for calculating the QPA artificially deflates the QPA by:
Establishing each contracted rate as a single data point
Excluding incentive-based and retrospective payments
Including rates for physicians in different specialties
Allowing third-party administrators to determine the QPA based on contracted rates recognized by all self-insured group health plans administered by the third-party administrator
"The inaccurately calculated QPA compounds the defects of the biased IDR process under the August final rule, which favors the QPA and empowers insurers to significantly reduce their in-network rates or terminate in-network agreements altogether," the groups say.
HealthLeaders' regulatory round up series highlights five essential governing updates that cover every aspect of the revenue cycle that leaders need to know. Check back in each month for more updates.
The revenue cycle is complex, detailed, and always changing, so staying on top of regulatory updates and latest best practices requires revenue cycle leaders' constant attention in this ever-changing industry.
In this revenue cycle regulatory roundup, there were an ample number of updates published by CMS and the OIG in January, including ICD-10-CM code updates and the OIG’s Work Plan.
The PHE is seeing an end.
The COVID-19 public health emergency (PHE) will end on May 11 according to a policy statement released by the Office of Management and Budget opposing House resolutions that would end the emergencies immediately if passed.
This will have implications on reimbursement for the revenue cycle, so stay tuned for future coverage.
New diagnosis codes were release, effective in April.
CMS should bolster its oversight of ASP data, the OIG says.
The OIG published a review of CMS’ oversight of manufacturer-reported average sales price (ASP) data, as the data is used to help calculate Part B payments and therefore there are concerns about the impact of inaccurate data on Part B spending.
The OIG found that there were gaps in CMS’ oversight of this data, as CMS’ quality assurance procedures did not include checks to ensure the accuracy of manual processes employed to analyze the data used to calculate Part B payment amounts.
The OIG also found CMS does not leverage its data collection system to produce reports that could monitor ASP data quality and aid in oversight. Because of invalid or missing data, CMS had issues calculating ASP-based payment amounts for a small amount of drug codes, and that can often lead to higher drug payment amounts for Part B drugs.
The OIG also found that 24% of drug codes were missing ASP data for drugs within that code in at least one quarter from 2016-2020. The OIG recommends CMS determine a strategy to strengthen its internal controls for ensuring the accuracy of Part B drug payments. CMS concurred with the OIG recommendations.
CMS slid in an update to the OPPS.
CMS published Medicare Claims Processing Transmittal 11801, which updated tables 5, 6, and added table 20 in the OPPS rule. This change updates the pass-through status of five devices that will now have an extended pass-through status for a one-year period beginning on January 1, 2023.
OIG updated its Work Plan.
The OIG updated its Work Plan and will be setting its sights on the following new items:
The Texas Medical Association (TMA) is suing HHS for the fourth time, this time for its 600% price increase pertaining to an aspect of the No Surprises Act.
That didn’t take long.
The independent dispute resolution (IDR) process has gotten more expensive for healthcare organizations, and now groups are demanding a reverse from HHS.
As HealthLeaders previously reported, it was announced that the nonrefundable administrative fee due from each party involved in any IDR payment dispute that goes to arbitration increased from $50 to $350. This 600% increase began January 1.
Revenue cycle leaders are trying to find ways to increase their bottom lines for 2023, and this news was a step in the wrong direction, especially for smaller healthcare organizations. At the time, we mentioned that this price hike may put organizations in a losing situation as they consider whether to formally dispute a payer’s proposed out-of-network payment amount.
The TMA says its newest lawsuit against federal agencies challenges the steep administrative fee hike that will strip many physicians and healthcare providers of the arbitration process that Congress enacted. These fees are "arbitrary and capricious, contrary to the law, and in violation of notice and comment requirements," TMA said in a statement.
The initial administrative fee for the IDR process was set at $50 and it was announced in October 2022 it would remain at $50 for 2023, but in January, the agencies revealed a 600% hike in the fee due to increasing expenditures in the IDR process, among other reasons.
"The steep jump in fees will dramatically curtail many physicians’ ability to seek arbitration when a health plan offers insufficient payment for care," the TMA said.
"The problem is that many payment disputes in these cases amount to less than the fees physicians would have to pay to dispute the unfair payments," said TMA President Gary W. Floyd, MD, in a statement.
"Why would doctors and providers pay the $350 nonrefundable administrative fee to arbitrate a $200 or so payment dispute with a health insurer? The fees deny physicians the ability to formally seek fair payment for taking care of our patients, and that’s just wrong," Floyd said.
The suit lists two radiology groups as plaintiffs: the Texas Radiological Society and Houston Radiology Associated. These groups bill small value claims, so they will be particularly hurt because most claims billed are less than $350, according to the suit.
Although the fee hike takes the focus of this suit, the TMA also disputes the rules’ narrowing of the law’s provisions on “batching” claims for arbitration, which Congress authorized to encourage efficiency and minimize costs in the IDR process, the TMA said.
As mentioned, this is the fourth suit filed by the TMA regarding nuances found within the No Surprises Act. Catch up on HealthLeader’s coverage here.
Creating an effective revenue cycle auditing and monitoring plan may require help from multiple departments.
Revenue cycle leaders are paying closer attention to their auditing strategies as costs rise, denials pour in, and payers tighten their grips.
It’s not unusual for an organization’s auditing responsibilities to fall on the revenue integrity department, but when looking to expand efforts, who should be recruited to help and what would their role be?
The National Association of Healthcare Revenue Integrity recently answered this question in the Revenue Integrity Insider. Read below to see the association’s answer.
Answer: Compliance and privacy must collaborate with revenue cycle and revenue integrity professionals to establish a proactive auditing and monitoring plan each fiscal year.
This plan would be based on the following:
Activity from previous self-audits
Activity from previous payer audits
Activity within the organization’s state
Reviews conducted by the OIG
Audits conducted by the organization’s Medicare Administrative Contractor and state Medicaid agency
It’s best practice for the organization to establish a monthly meeting between revenue cycle, compliance, and privacy professionals to share plans for auditing and monitoring as well as to go over OIG reviews. The group should review areas in which claims need to be refunded to a specific payer so they can discuss the source of the error and the mitigation plan to ensure that the error does not occur in the future.
Federal guidelines state the organization can take up to six months to quantify an error once discovered. That said, at or before the six-month mark, once quantified, the organization has up to 60 days to refund the appropriate payer.
Best practice would be for one individual in the organization to track all of those associated refunds and due dates to be reviewed by the joint revenue cycle, compliance, and privacy team so that all deadlines can be maintained and reported quarterly to the governing body of the organization.
Compliance and privacy staff will also provide guidance on privacy questions and release of medical record information as situations arise within the revenue cycle.
The AVP of revenue cycle management at Geisinger Health System discusses the necessity of the IT department when automating in the revenue cycle.
Most revenue cycle leaders have started implementing automation in one sector or another of their department, but while automation may seem like a simple fix, collaboration is usually needed with teams beyond the revenue cycle.
More leaders are bringing in their IT teams to help streamline their revenue cycle automation, and as Christy Pehanich, AVP of revenue cycle management at Geisinger Health System, says, collaborating with IT and merging skill sets is a necessity in optimizing revenue cycle automation.
HealthLeaders: What do you see for the future of automation related to revenue cycle and IT?
Pehanich: I think that we are just starting to learn how to properly leverage automation in revenue cycle. I think there's certainly going to be a lot of opportunities for IT professionals that have revenue cycle domain expertise.
We have a lot of really smart IT engineers and application developers out there, but they do not have any revenue cycle domain expertise, and we really need to merge those skill sets in order to optimize automation in the revenue cycle.
We need to create more opportunities for IT professionals and for revenue cycle experts to merge those skills through education. Just understanding the languages in each department in and of itself can be a challenge. There are so many different acronyms that get thrown out when you start talking about automation and revenue cycle, so both teams need to know what the other is saying.
The big opportunity is to merge revenue cycle domain expertise with IT expertise and once that happens, the future of automation is limitless. Really.
Photo: Christy Pehanich, AVP of Revenue Management, Geisinger Health System. Courtesy of Robb Malloy/Geisinger
HealthLeaders: How are you working to close that gap between revenue cycle staff and other departments like IT at Geisinger?
Pehanich: It's just about collaboration and taking the time to collaborate and share what each other know.
You can no longer work in isolation or in silos where revenue cycle management is behind the scenes and not collaborating with our clinical enterprise partners or our IT partners.
That type of traditional revenue cycle is not going to be able to succeed in the future. I think that it's largely about collaboration, coordination, and taking the time to talk to one another. You need to agree on opportunities and create a task force for shared learning across all departments.
SDOH capture can result in improved patient satisfaction scores and reduced provider burnout.
The CDC recently announced 42 new ICD-10-CM diagnosis codes for 2023 effective April 1. Taking the spotlight for these changes are new codes for reporting certain social determinants of heath (SDOH).
With increasing attention on population health and quality initiatives, organizations have turned their focus on SDOH and how capturing those ICD-10-CM codes impacts their patient population and their success in caring for that population.
Capturing SDOH is critical for revenue cycle teams. SDOH data can provide revenue cycle leaders with a better understanding of patient populations to inform revenue planning and strategy.
The caveat though, is that SDOH codes are not currently tied to reimbursement, meaning SDOH capture isn’t on the list of priorities for leaders. But, as Eric Penniman, DO, executive director of Summit Medical Group, recently said, there are many more positives to collecting this data, including reduced provider frustration and burnout.
“I’ve seen many family doctors over the years get frustrated because the patient didn’t show up for the appointment. Or they showed up for the appointment and they hadn’t started their meds,” Penniman explained during the 2023 CPT/RBRVS Annual Symposium, Part B News reported.
“And ultimately you see the lightbulb come on for them when [the provider realizes], ‘Oh, the patient didn’t show up for their appointment because they didn’t have a ride to the appointment, because they live in a homeless shelter and couldn’t access a ride,’” he said.
Documenting and coding a patient’s SDOH can create a shorthand that alerts the care team to challenges the patient is facing, Part B News said. In the example of the patient who lives in a homeless shelter, the diagnosis codes for transportation insecurity and sheltered homelessness explain why the patient regularly misses appointments.
SDOH codes for a patient’s intentional underdosing of medication regimen due to a financial hardship can explain why a patient didn’t get a prescription filled or isn’t taking the medicine as directed.
In both cases, the SDOH codes turn frustrating events with no solution into situations that can be addressed.
“These are the things we’re focusing on,” added Ericka Panek, MHIM, MSSW, LCSW, data analyst for the Summit Medical Group, during the same presentation, “getting that person to their appointment and making sure that everyone’s aware that is a barrier. And if it is, can we work with community resources and partners and can we get that patient a ride, or can we get in-home services that allow them to be able to do that?”
In turn, that can lead to better patient care.
“The pieces about our patients that we don’t understand. . . actually lead physicians toward burnout, because they get frustrated. And when you better understand your patients, and you begin to empathize a little bit with their circumstances, I think it can help reduce burnout in primary care as well as—obviously—provide better care for our patients,” Penniman said.
“Everyone deserves that fair chance at care. And documenting that brings more attention to where this barrier may lie,” Panek said.
Better understanding patients’ needs and preferences can result in improved patient satisfaction scores, a key factor in revenue reimbursement. Capturing SDOH information will create the opportunity for your revenue cycle to make informed decisions that will help to improve reimbursement rates while providing quality care for patients.
Emergency physician groups outline solutions to improve the surprise billing law in a recently published letter.
The American College of Emergency Physicians (ACEP) and the Emergency Department Practice Management Association (EDPMA) recently outlined solutions to address the significant challenges facing emergency physicians who try to use the independent dispute resolution (IDR) process.
In the letter sent to the U.S. Departments of Health and Human Services, Labor, and Treasury, the groups outline the various ways these burdens related to the No Surprises Act can be alleviated moving forward.
For background, the administrative burden related to the No Surprises Act has been heavy for revenue cycle staff.
As outlined in the letter, with respect to scheduled healthcare, administrative staff not only verify first-level insurance information, but they also drill down to the patient’s individual health plan type before the patient enters the exam room or treatment space.
As the ACEP and EDPMA emphasize in the letter, emergency room visits are a whole other ball game.
In this setting, revenue cycle staff must wait until after the episode of care has occurred, and then wade through individual policy benefits, relying on costly and time-consuming administrative back and-forth that may even involve the patient for more clarification, the letter says.
These special circumstances have led to an immediate need for policy adjustment, the groups say.
The groups’ 17-page letter summarizes the major issues that these providers are experiencing and provides detail about the recommendations discussed during a January meeting including the Departments, emergency physicians, insurers, and others.
Stakeholders at the meeting agreed that the statute’s lack of clarity on how to open negotiations before resorting to an independent arbiter impacts engagement in the process.
Also, the lack of information sharing from payers is delaying the IDR process before it even begins and “makes it difficult for providers and eventually for certified IDR entities to determine whether a claim is eligible for the federal IDR process,” the letter states.
During the meeting, concerns were also expressed that the qualified payment amount (QPA) methodology finalized by the departments is leading to artificially low QPAs that do not reflect market rates for services, the letter says. Further, payers are miscalculating the QPA, which drives payments down even lower.
“This combination of the QPA methodology and the miscalculations has led to QPAs that ‘don’t even pass the laugh test’—those that are so low that they are even significantly below Medicare and Medicaid payment rates,” the groups say.
The letter even outlines the experience of one physician group that said it has not received payments in more than 90% of the cases in which the IDR entity ruled in its favor.
